1
|
Geßele C, Saller T, Smolka V, Dimitriadis K, Amann U, Strobach D. Development and validation of a new drug-focused predictive risk score for postoperative delirium in orthopaedic and trauma surgery patients. BMC Geriatr 2024; 24:422. [PMID: 38741037 PMCID: PMC11092087 DOI: 10.1186/s12877-024-05005-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/24/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Postoperative delirium (POD) is the most common complication following surgery in elderly patients. During pharmacist-led medication reconciliation (PhMR), a predictive risk score considering delirium risk-increasing drugs and other available risk factors could help to identify risk patients. METHODS Orthopaedic and trauma surgery patients aged ≥ 18 years with PhMR were included in a retrospective observational single-centre study 03/2022-10/2022. The study cohort was randomly split into a development and a validation cohort (6:4 ratio). POD was assessed through the 4 A's test (4AT), delirium diagnosis, and chart review. Potential risk factors available at PhMR were tested via univariable analysis. Significant variables were added to a multivariable logistic regression model. Based on the regression coefficients, a risk score for POD including delirium risk-increasing drugs (DRD score) was established. RESULTS POD occurred in 42/328 (12.8%) and 30/218 (13.8%) patients in the development and validation cohorts, respectively. Of the seven evaluated risk factors, four were ultimately tested in a multivariable logistic regression model. The final DRD score included age (66-75 years, 2 points; > 75 years, 3 points), renal impairment (eGFR < 60 ml/min/1.73m2, 1 point), anticholinergic burden (ACB-score ≥ 3, 1 point), and delirium risk-increasing drugs (n ≥ 2; 2 points). Patients with ≥ 4 points were classified as having a high risk for POD. The areas under the receiver operating characteristic curve of the risk score model were 0.89 and 0.81 for the development and the validation cohorts, respectively. CONCLUSION The DRD score is a predictive risk score assessable during PhMR and can identify patients at risk for POD. Specific preventive measures concerning drug therapy safety and non-pharmacological actions should be implemented for identified risk patients.
Collapse
Affiliation(s)
- Carolin Geßele
- Hospital Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany.
- Doctoral Program Clinical Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany.
| | - Thomas Saller
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Vera Smolka
- Department of Orthopaedics and Trauma Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Ute Amann
- Faculty of Medicine, LMU Munich, Munich, Germany
| | - Dorothea Strobach
- Hospital Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany
- Doctoral Program Clinical Pharmacy, LMU University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
2
|
Wischmann J, Kremer P, Hinske L, Tomasi R, Becker-Pennrich AS, Kellert L. The RAPID-score: Risk Assessment and PredIction of Delirium in acute stroke patients based on very early clinical parameters. Front Neurol 2023; 14:1306520. [PMID: 38162448 PMCID: PMC10756062 DOI: 10.3389/fneur.2023.1306520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/01/2023] [Indexed: 01/03/2024] Open
Abstract
Background and objective Post-stroke delirium (PSD) is a common complication in acute stroke patients, and guidelines recommend routine screening and various preventive and treatment measures. However, there is a substantial lack of standardized approaches in diagnostic and therapeutic management of PSD. Here, we aimed to develop a new pragmatic and easily assessable screening tool to predict PSD based on early parameters, which are already integral to acute stroke diagnostics. Methods We enrolled acute stroke patients admitted to our stroke unit or intensive care unit and developed the scoring system using retrospective single-center patient data. The Confusion Assessment Method for the Intensive Care Unit was used for prospective score validation. Logistic regression models were employed to analyze the association of early clinical and paraclinical parameters with PSD development. Results N = 525 patients (median age: 76 years; 45.7% female) were enrolled, with 29.7% developing PSD during hospitalization. The resulting score comprises 6 items, including medical history, clinical examination findings, and non-contrast computed tomography results at admission. Scores range from -15 to +15 points, with higher values indicating a higher likelihood of PSD, ranging from 4% to 79%. The accuracy was 0.85, and the area under the curve was 0.89. Conclusion The new RAPID (Risk Assessment and PredIction of Delirium in acute stroke patients)-score shows high accuracy in predicting PSD among acute stroke patients and offers precise odds of PSD for each corresponding score value, utilizing routine early clinical and paraclinical parameters. It can identify high-risk populations for clinical study interventions and may be suitable to guide prophylactic PSD measures.
Collapse
Affiliation(s)
- Johannes Wischmann
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Pauline Kremer
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Ludwig Hinske
- Department of Anesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
- Institute for Digital Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Roland Tomasi
- Department of Anesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Andrea S. Becker-Pennrich
- Department of Anesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
- Faculty of Medicine, Pettenkofer School of Public Health, Institute for Medical Information Processing, Biometry and Epidemiology (IBE), LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
3
|
Siokas V, Fleischmann R, Feil K, Liampas I, Kowarik MC, Bai Y, Stefanou MI, Poli S, Ziemann U, Dardiotis E, Mengel A. The Role of Vascular Risk Factors in Post-Stroke Delirium: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:5835. [PMID: 36233701 PMCID: PMC9571874 DOI: 10.3390/jcm11195835] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/12/2022] [Accepted: 09/28/2022] [Indexed: 11/09/2022] Open
Abstract
Vascular risk factors may predispose to post-stroke delirium (PSD). A systematic review and meta-analysis were performed by searching PubMed, Web of Science, and Scopus. The primary outcome was the prevalence of vascular risk factors in PSD vs. non-PSD patients. Odds ratios (ORs) with 95% confidence intervals (CIs) and mean differences (MDs) with 95% CIs were calculated for categorical and continuous variables, respectively. Fixed effects or random effects models were used in case of low- or high-statistical heterogeneity, respectively. We found an increased prevalence of atrial fibrillation (OR = 1.74, p = 0.0004), prior stroke (OR = 1.48, p < 0.00001), coronary artery disease (OR = 1.48, p < 0.00001), heart failure (OR = 2.01, p < 0.0001), and peripheral vascular disease (OR = 2.03, p < 0.00001) in patients with vs. without PSD. PSD patients were older (MD = 5.27 y, p < 0.00001) compared with their non-PSD counterparts. Advanced age, atrial fibrillation, prior stroke, coronary artery disease, heart failure, and peripheral vascular disease appeared to be significantly associated with PSD.
Collapse
Affiliation(s)
- Vasileios Siokas
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
- Department of Neurology, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41100 Larissa, Greece
| | - Robert Fleischmann
- Department of Neurology, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Katharina Feil
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
| | - Ioannis Liampas
- Department of Neurology, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41100 Larissa, Greece
| | - Markus C. Kowarik
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
| | - Yang Bai
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
- School of Basic Medical Sciences, Hangzhou Normal University, Hangzhou 310030, China
| | - Maria-Ioanna Stefanou
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41100 Larissa, Greece
| | - Annerose Mengel
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, 72076 Tübingen, Germany
| |
Collapse
|
4
|
Callea A, Conti G, Fossati B, Carassale L, Zagaria M, Caporotundo S, Ziglioli E, Brunetti V, Della Marca G, Rollo E. Delirium in hospitalized patients with COVID-19 pneumonia: a prospective, cross-sectional, cohort study. Intern Emerg Med 2022; 17:1445-1452. [PMID: 35084645 PMCID: PMC8793095 DOI: 10.1007/s11739-022-02934-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 01/15/2022] [Indexed: 12/15/2022]
Abstract
Delirium is an acute confusional state characterized by altered level of consciousness and attention. Coronavirus Disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), can manifest itself with this neuropsychiatric disorder. The endpoints of our study were: the frequency of delirium in subjects with COVID-19 pneumonia; the risk factors that predispose to this condition; and the impact of delirium on mortality. Subjects were consecutively enrolled in a Geriatric Unit from January 5th to March 5th, 2021. Inclusion criteria were: diagnosis of SARS-CoV-2 infection, a radiologically documented pneumonia, and the ability of providing informed consent. Exclusion criteria were: absence of radiological evidence of pneumonia, sepsis, and the need of intensive care unit treatment. All subjects were evaluated by means of Richmond Agitation Sedation Scale (RASS) and Confusion Assessment Method-Intensive Care Unit (CAM-ICU) at least twice per day. In the study cohort (n = 71), twenty patients (28.2%) had delirium. Delirium was present on admission in 11.3%, and occurred during hospitalization in 19.0%. Compared to patients without delirium, patients who developed this neuropsychiatric disorder had a higher mortality rate (35% vs 5.9%) and an increased average hospital length of stay (21 days vs 17 days). In the multivariate analysis delirium was associated with frailty (OR = 2.81; CI = 1.4-5.8) and helmet ventilation (OR = 141.05; CI = 4.3-4663.9). Delirium was an independent predictor of mortality. Nearly a third of subjects (28.2%) had delirium during hospitalization for COVID-19. This finding supports the notion that delirium is a common complication of SARS-CoV2 infection. Since delirium is associated with longer hospital stay, and it is an independent marker of increased mortality, clinicians should assess and prevent it.
Collapse
Affiliation(s)
- Antonio Callea
- Department of Neurology, ASST Nord Milano, Ospedale Bassini, Via Massimo Gorki, 50, 20092, Milan, Cinisello Balsamo, Italy.
| | - Giancarlo Conti
- Department of Neurology, ASST Nord Milano, Ospedale Bassini, Via Massimo Gorki, 50, 20092, Milan, Cinisello Balsamo, Italy
| | - Barbara Fossati
- Department of Neurology, ASST Nord Milano, Ospedale Bassini, Via Massimo Gorki, 50, 20092, Milan, Cinisello Balsamo, Italy
| | - Laura Carassale
- Department of Geriatrics, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, Milan, Italy
| | - Mariapia Zagaria
- Department of Geriatrics, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, Milan, Italy
| | - Silvia Caporotundo
- Department of Geriatrics, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, Milan, Italy
| | - Eleonora Ziglioli
- Department of Geriatrics, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo, Milan, Italy
| | - Valerio Brunetti
- Dipartimento Scienze Dell'Invecchiamento, Neurologiche, Ortopediche E Della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giacomo Della Marca
- Dipartimento Scienze Dell'Invecchiamento, Neurologiche, Ortopediche E Della Testa-Collo, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eleonora Rollo
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
5
|
Rollo E, Marotta J, Callea A, Brunetti V, Vollono C, Scala I, Imperatori C, Frisullo G, Broccolini A, Della Marca G. Heart rate variability and delirium in acute non-cardioembolic stroke: a prospective, cross-sectional, cohort study. Neurol Sci 2022; 43:2423-2431. [PMID: 34586543 PMCID: PMC8918184 DOI: 10.1007/s10072-021-05621-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/17/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Delirium is an acute fluctuating disorder of attention and awareness. It is associated with autonomic dysfunction and increased mortality. The primary endpoint of our study was to measure autonomic activity in acute stroke patients, by means of heart rate variability analysis, in order to identify autonomic modifications that can predispose to delirium. METHODS Patients were consecutively enrolled from the stroke unit. Inclusion criteria were age ≥ 18 years and diagnosis of stroke with onset within the previous 72 h confirmed by neuroimaging. Exclusion criteria were atrial fibrillation, congestive heart failure, and conditions requiring intensive care unit. Patients were evaluated by means of Richmond Agitation Sedation Scale (RASS) and Confusion Assessment Method-Intensive Care Unit (CAM-ICU) at baseline, after 72 h, or when symptoms suggesting delirium occurred. For each patient, ECG was recorded at baseline assessment and HRV analysis was conducted on five consecutive minutes of artifact-free ECG traces. RESULTS Fifty-six ECGs were available for analysis. During the study period, 11 patients developed delirium. Patients with and without delirium did not differ for sex, age, severity of stroke, and comorbidities. The delirium group had greater standard deviation of the heart rate (DLR - :9.16 ± 8.28; DLR + : 14.36 ± 5.55; p = 0.026) and lower power spectral density of the HF component (DLR - : 38.23 ± 19.23 n.u.; DLR + : 25.75 ± 8.77 n.u.; p = 0.031). CONCLUSIONS Acute non-cardioembolic stroke patients with increased variability of heart rate and decreased vagal control are at risk for delirium.
Collapse
Affiliation(s)
- Eleonora Rollo
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Jessica Marotta
- UOC Neuroriabilitazione Ad Alta Intensità, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio Callea
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Valerio Brunetti
- Dipartimento Scienze Dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Catello Vollono
- Dipartimento Scienze Dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Irene Scala
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | | | - Giovanni Frisullo
- Dipartimento Scienze Dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Aldobrando Broccolini
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
- Dipartimento Scienze Dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giacomo Della Marca
- Department of Neurosciences, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
- Dipartimento Scienze Dell'Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| |
Collapse
|
6
|
Quinn TJ, Richard E, Teuschl Y, Gattringer T, Hafdi M, O'Brien JT, Merriman N, Gillebert C, Huygelier H, Verdelho A, Schmidt R, Ghaziani E, Forchammer H, Pendlebury ST, Bruffaerts R, Mijajlovic M, Drozdowska BA, Ball E, Markus HS. European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment. Eur J Neurol 2021; 28:3883-3920. [PMID: 34476868 DOI: 10.1111/ene.15068] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/13/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE The optimal management of post-stroke cognitive impairment (PSCI) remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making regarding prevention, diagnosis, treatment and prognosis. METHODS Guidelines were developed according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations. RESULTS There was limited randomized controlled trial (RCT) evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Lifestyle interventions and treating vascular risk factors have many health benefits, but a cognitive effect is not proven. We found no evidence regarding routine cognitive screening following stroke, but recognize the importance of targeted cognitive assessment. We describe the accuracy of various cognitive screening tests, but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognition. The association between PSCI and acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on brain magnetic resonance imaging may help predict cognitive outcomes. CONCLUSIONS These guidelines highlight fundamental areas where robust evidence is lacking. Further definitive RCTs are needed, and we suggest priority areas for future research.
Collapse
Affiliation(s)
- Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Behaviour and Cognition, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Yvonne Teuschl
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria
| | - Thomas Gattringer
- Department of Neurology and Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Melanie Hafdi
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - John T O'Brien
- Department of Psychiatry, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Niamh Merriman
- Department of Health Psychology, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Celine Gillebert
- Department Brain and Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium.,TRACE, Centre for Translational Psychological Research (TRACE), KU Leuven - Hospital East-Limbourgh, Genk, Belgium
| | - Hanne Huygelier
- Department Brain and Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium.,TRACE, Centre for Translational Psychological Research (TRACE), KU Leuven - Hospital East-Limbourgh, Genk, Belgium
| | - Ana Verdelho
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Lisbon, Portugal
| | - Reinhold Schmidt
- Department of Neurology and Medical University of Graz, Graz, Austria
| | - Emma Ghaziani
- Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | | | - Sarah T Pendlebury
- Departments of Medicine and Geratology and NIHR Oxford Biomedical Research Centre Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Rose Bruffaerts
- Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Milija Mijajlovic
- Neurosonology Unit, Neurology Clinic, University Clinical Center of Serbia and Faculty of Medicine University of Belgrade, Belgrade, Serbia
| | - Bogna A Drozdowska
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Emily Ball
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hugh S Markus
- Stroke Research group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| |
Collapse
|
7
|
Quinn TJ, Richard E, Teuschl Y, Gattringer T, Hafdi M, O’Brien JT, Merriman N, Gillebert C, Huyglier H, Verdelho A, Schmidt R, Ghaziani E, Forchammer H, Pendlebury ST, Bruffaerts R, Mijajlovic M, Drozdowska BA, Ball E, Markus HS. European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment. Eur Stroke J 2021; 6:I-XXXVIII. [PMID: 34746430 PMCID: PMC8564156 DOI: 10.1177/23969873211042192] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 01/14/2023] Open
Abstract
The optimal management of post-stroke cognitive impairment remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making around prevention, diagnosis, treatment and prognosis. These guidelines were developed according to ESO standard operating procedure and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and, where possible, meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. There was limited randomised controlled trial evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Interventions to improve lifestyle and treat vascular risk factors may have many health benefits but a beneficial effect on cognition is not proven. We found no evidence around routine cognitive screening following stroke but recognise the importance of targeted cognitive assessment. We described the accuracy of various cognitive screening tests but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognitive syndromes (cognitive impairment, dementia and delirium). The association between post-stroke cognitive impairment and most acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on acute MRI brain may help predict cognitive outcomes. These guidelines have highlighted fundamental areas where robust evidence is lacking. Further, definitive randomised controlled trials are needed, and we suggest priority areas for future research.
Collapse
Affiliation(s)
- Terence J Quinn
- Institute of Cardiovascular and
Medical Sciences, University of Glasgow, Glasgow, UK
| | - Edo Richard
- Department of Neurology, Donders
Institute for Brain, Behaviour and Cognition, Radboud University Medical
Centre, Nijmegen, The Netherlands
| | - Yvonne Teuschl
- Department for Clinical
Neurosciences and Preventive Medicine, Danube University Krems, der Donau, Austria
| | - Thomas Gattringer
- Department of Neurology and
Division of Neuroradiology, Vascular and Interventional Radiology, Department of
Radiology, Medical University of
Graz, Graz, Austria
| | - Melanie Hafdi
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - John T O’Brien
- Department of Psychiatry, University of Cambridge School of
Clinical Medicine, Cambridge, UK
| | - Niamh Merriman
- Deptartment of Health Psychology,
Division of Population Health Sciences, Royal College of Surgeons in
Ireland, Dublin, Ireland
| | - Celine Gillebert
- Department Brain & Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- TRACE, Centre for Translational
Psychological Research (TRACE), KU Leuven – Hospital
East-Limbourgh, Genk, Belgium
| | - Hanne Huyglier
- Department Brain & Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- TRACE, Centre for Translational
Psychological Research (TRACE), KU Leuven – Hospital
East-Limbourgh, Genk, Belgium
| | - Ana Verdelho
- Department of Neurosciences and
Mental Health, Hospital de Santa Maria, Lisbon, Portugal
| | - Reinhold Schmidt
- Department of Neurology, Medical University of
Graz, Graz, Austria
| | - Emma Ghaziani
- Department of Physical and
Occupational Therapy, Bispebjerg and Frederiksberg
Hospital, Copenhagen, Denmark
| | | | - Sarah T Pendlebury
- Departments of Medicine and
Geratology and NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS
Foundation Trust, Oxford, UK
| | - Rose Bruffaerts
- Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - Milija Mijajlovic
- Neurosonology Unit, Neurology
Clinic, University Clinical Center of Serbia
and Faculty of Medicine University of Belgrade, Belgrade, Serbia
| | - Bogna A Drozdowska
- Institute of Cardiovascular and
Medical Sciences, University of Glasgow, Glasgow, UK
| | - Emily Ball
- Centre for Clinical Brain
Sciences, University of Edinburgh, Edinburgh, Scotland
| | - Hugh S Markus
- Stroke Research Group, Department
of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| |
Collapse
|
8
|
Ding G, Hua S, Chen J, Yang S, Xie R. Does cognitive decline/dementia increase Delirium risk after stroke? Psychogeriatrics 2021; 21:605-611. [PMID: 34018278 DOI: 10.1111/psyg.12720] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/20/2021] [Accepted: 05/09/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Delirium is a common contributor to mortality and hospital costs in stroke patients. Different observational studies have showed inconsistent results regarding the association between cognitive decline/dementia and delirium after acute stroke. Therefore, we performed this meta-analysis with the aim of determining whether cognitive decline/dementia is related to the risk of delirium after acute stroke. METHODS We systematically searched PubMed, Embase, Google Scholar, and Web of Science for relevant studies from inception to September 2020. We calculated the pooled odds ratio (OR) with 95% confidence interval (CI) by using fixed or random effects models based on heterogeneity measured by the I2 index. RESULTS The association between cognitive decline/dementia and post-stroke delirium was examined in 13 studies with 3183 participants. After pooled analysis, we found that cognitive decline/dementia was significantly associated with susceptibility to delirium in post-stroke patients (OR = 3.70, 95%CI: 2.90-4.71, P < 0.001). Subgroup analysis suggested that cognitive decline/dementia was associated with an increased risk of delirium in Caucasians (OR = 3.73, 95%CI: 2.73-5.11, P < 0.001), non-Caucasians (OR = 3.65, 95%CI: 2.50-5.33, P < 0.001), samples with <200 subjects (OR = 3.70, 95%CI: 2.17-6.31, P < 0.001), samples with ≥200 subjects (OR = 3.70, 95%CI: 2.82-4.85, P < 0.001), studies published in 1990-2009 (OR = 3.17, 95%CI: 1.48-6.77, P = 0.003), and studies published in 2010-2020 (OR = 3.76, 95%CI: 2.92-4.86, P < 0.001). CONCLUSIONS We identified an association between cognitive decline/dementia and the risk of developing delirium. Cognitive decline/dementia may be a promising predictor for delirium in post-stroke patients.
Collapse
Affiliation(s)
- Guanfu Ding
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Neurology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Shunde Hua
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Neurology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Jinming Chen
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Neurology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Shaochun Yang
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Neurology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Ruilu Xie
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Institute of Neurology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.,Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases, Ministry of Education, Gannan Medical University, Ganzhou, China
| |
Collapse
|
9
|
Nakamizo T, Kanda T, Kudo Y, Sugawara E, Hashimoto E, Okazaki A, Usuda M, Nagai T, Hara H, Johkura K. Effects of uncomfortable care and histamine H2-antagonists on delirium in acute stroke: A propensity score analysis. J Neurol Sci 2020; 420:117251. [PMID: 33276246 DOI: 10.1016/j.jns.2020.117251] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/28/2020] [Accepted: 11/23/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Uncomfortable care and histamine H2 antagonist (H2A) are implicated in precipitating delirium. In acute stroke, however, the need for them depends on stroke severity, an established risk factor for delirium. So, it is unclear whether care or H2A itself is responsible for delirium. We aimed to evaluate their causal effects on delirium in acute stroke patients. METHODS This is a prospective cohort study on acute stroke patients admitted to a stroke care unit. Patients without stupor, coma, sedation, or delirium upon admission were enrolled. The treatment was H2A and five care modalities given during the first 24 h: restraint use, prohibited self-transfer, no oral feeding, indwelling catheters, and frequent nighttime care. The outcome was delirium within 5 days defined as Intensive Care Delirium Screening Checklist ≥4 points. We estimated the relative risk (RR) for delirium with regression models weighted by overlap weights using propensity scores estimated through logistic models incorporating known and potential confounders, including stroke severity. RESULTS Of the 387 participants, 188 were given at least one care modality and 130 were given H2A. A total of 42 developed delirium. Delirium was significantly associated with prohibited self-transfer (RR 1.7, 95% CI 1.0-3.0), frequent nighttime care (RR 2.1, 95% CI 1.2-3.7), and multiple care modalities (RR 2.4, 95% CI 1.3-4.4), while other care modalities and H2A were not. CONCLUSIONS This study showed possible causal effects of uncomfortable care on delirium and suggests that minimizing it could prevent delirium in acute stroke.
Collapse
Affiliation(s)
- Tomoki Nakamizo
- Department of Neurology, Yokohama Brain and Spine Center, Yokohama, Japan; Department of Clinical Studies, Radiation Effects Research Foundation, Nagasaki, Japan
| | - Toshie Kanda
- Department of Nursing, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Yosuke Kudo
- Department of Neurology, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Eriko Sugawara
- Department of Neurology, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Erina Hashimoto
- Department of Nursing, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Ayana Okazaki
- Department of Nursing, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Makoto Usuda
- Department of Pharmacy, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Toru Nagai
- Department of Pharmacy, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Hiroshi Hara
- Department of Pharmacy, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Ken Johkura
- Department of Neurology, Yokohama Brain and Spine Center, Yokohama, Japan.
| |
Collapse
|